HIV Prevention: Clinical Decision Support System to Increase HIV Screening

HIV Prevention: Clinical Decision Support System to Increase HIV Screening

Context

  • In 2018, approximately 1.04 million adults and adolescents in the U.S. were living with diagnosed HIV infection.
  • Approximately 38,000 new HIV diagnoses occurred in the same year (CDC 2020).
  • Highest rates of diagnosis observed in:
    • Individuals aged 20-29 years.
    • Black or African American individuals.
    • Those with male-to-male sexual contact.
    • People residing in the southern states.
  • National goal: Reduce new HIV infections by 75% in 5 years, 90% in 10 years (Ending the HIV Epidemic initiative).
  • Key strategies include:
    • Early diagnosis of individuals living with HIV.
    • Linking diagnosed individuals to care and treatment to achieve viral suppression, reducing transmission.
  • National Strategic Plan (2021-2025) complements the above initiative focusing on improved health outcomes and reduced health disparities.
  • Importance of increasing HIV screening among high-risk populations to facilitate early testing.

Intervention Definition

  • Clinical Decision Support Systems (CDSS): Tools designed to enhance decision-making in patient care. Specific types of CDSS include:
    • Computerized alerts and reminders for providers and patients.
    • Clinical guidelines and order sets specific to conditions.
    • Patient data reports and summaries.
    • Documentation templates and diagnostic support (Office of the National Coordinator for Health Information Technology, 2018).
  • In the context of HIV screening, CDSS utilizes:
    • Patient data and guidelines to identify potential candidates for HIV testing.
    • Alerts and reminders to healthcare providers to encourage HIV testing based on patient eligibility.
  • CDC guidelines (Branson et al. 2006) recommend routine HIV screening for:
    • All individuals aged 13-64.
    • Pregnant individuals.
    • High-risk individuals on at least an annual basis (considering factors such as STD history, sexual behavior, or injection drug use).

CPSTF Finding (April 2020)

  • The Community Preventive Services Task Force (CPSTF) recommends CDSS for increasing HIV screening based on:
    • Strong evidence of effectiveness from systematic review studies.
    • Observations showing that CDSS can effectively increase HIV screenings in both general population and high-risk groups.
    • Enhanced identification of HIV cases and improved linkage to care:
    • CDSS effectively addresses health disparities among these populations.

Rationale

Basis of Finding

  • The CPSTF's recommendation is founded on a systematic review of 23 studies (1985 - 2019) evaluating CDSS effectiveness in increasing HIV screening.
  • Key findings from studies include:
    • Providers offered testing to a median of 80% of eligible patients, with a median of 30% declining the offer.
    • Compared to non-intervention setups, CDSS increased both screening rates and the identification of HIV infections.
    • Majority of patients testing positive were linked to care.
    • Increased identification of patients at earlier stages of HIV infection (according to CD4 count and viral load).
Table: Intervention Effects on HIV Screening Among Eligible Patients
  • Outcome Measures:
    • Percent of patients tested
    • Baseline: 6%
    • Post intervention: 16%
    • Absolute Change: +10.3 percentage points (range: 6.3 to 15.5)
    • Number of studies: 16
    • Number of patients tested per month:
    • Baseline: 80 tests/month
    • Post intervention: 495 tests/month
    • Absolute Change: +415 patients tested (range: 45 to 531)
    • Number of studies: 7
    • Number of patients who tested positive per month:
    • Baseline: 1.3 persons
    • Post intervention: 2.6 persons
    • Absolute Change: +1.3 persons (range: 0.02 to 2.8)
    • Number of studies: 13

Applicability and Generalizability Considerations

  • Intervention Settings:

    • Studies conducted primarily in the U.S. (21) and U.K. (2).
    • U.S. studies implemented across various regions: Western (6), Midwestern (4), Northeastern (8), Southern (4).
    • Context of urban (16), rural (2), or mixed settings (3).
    • Locations included clinics (8), hospitals (3), emergency departments (5), V.A. facilities (6), and managed care (1).
    • CDSS showed effectiveness in all settings evaluated.

  • Population Characteristics:

    • Screening increased across all age groups, especially noted for individuals aged 50 and older.
    • The interventions positively impacted all genders, income levels, and racial/ethnic groups.
    • Specific targeting of American Indian and Alaska Native populations allowed assessment of effectiveness.
    • Interventions were particularly beneficial for underserved populations, demonstrating potential to enhance health equity.

  • Intervention Characteristics:

    • Interventions generally ran for a median of 12 months and modified existing CDSS in EMR/EHR systems.
    • Two types of testing: Opt-out (19 studies) recommended by CDC and Opt-in (3 studies).
    • Alerts from CDSS were categorized as Active (13 studies) requiring acknowledgement and Passive (4 studies) ignored by providers.
    • Educational components for providers resulted in larger increases in HIV screenings, specifically when addressed prior to implementation.

Data Quality Issues

  • Most studies relied on pre-existing data from medical records leading to pre-post designs with convenience sampling, limiting broader applicability.

Other Benefits and Harms

  • No additional benefits or harms identified from studies.

Considerations for Implementation

  • Adaptation of EMR/EHR:

    • Widespread usage (96% of acute care hospitals, 85.9% of office physicians by 2017).
    • Need for systematic identification of risk behaviors in records for effective CDSS use.

  • Challenges:

    • Acceptance of HIV screening by providers in busy environments may vary; suitable timing for alerts is crucial.
    • Resistance in a fast-paced setting may necessitate streamlined protocols to enhance provider comfort.

  • Training:

    • Training providers can enhance effectiveness by minimizing disruptions.
    • Educating about biases regarding at-risk populations is vital.

  • Reducing Declines:

    • Need to understand reasons for opting out and offer alternatives for testing options (e.g., oral vs. needle stick).

  • Linkage to Care:

    • Essential follow-up mechanisms for those tested positive, including:
    • CDSS algorithms to facilitate confirmatory testing and referrals.
    • Engagement of outreach workers to provide support.

Evidence Gaps

  • Research is needed in the following areas:
    • Effectiveness of CDSS amongst high-risk behaviors (e.g., male-to-male contact, injection drug use, transgender populations).
    • CDSS performance efficacy specifically in rural locations.

References

  • Detailed studies and reports cited including Branson et al. (2006) on HIV testing recommendations and various journals reporting CDSS implementation outcomes.
  • Comprehensive list of sources provided includes official CDC reports, peer-reviewed studies, and public health documentation addressing HIV screening and decision support systems.

Disclaimer

  • The conclusions presented are from the Community Preventive Services Task Force and do not reflect CDC positions. These recommendations should be seen as options for decision-making rather than mandates for compliance.